“Tomorrow is the three-year anniversary of the passage of Obamacare,” Cruz said on the floor before the vote. “Obamacare is hurting young people. It’s hurting seniors. It’s hurting Hispanics. It’s hurting African-Americans. It’s hurting single moms. It’s hurting the economy. It should be repealed.”

House Minority Leader Nancy Pelosi, D-Calif., said that her party “honor[ed] the vows of our Founders” in passing Obamacare during a statement to mark the imminent third anniversary of the law’s passage.

“I see this as honoring the vows of our Founders, who sacrificed everything for life, liberty, pursuit of happiness,” Pelosi told reporters today. “Here we have a healthier life [and] the liberty to pursue your happiness — whether it’s to be a cameraman, a writer, self-employed, start your own business, change jobs, not be job-locked because of health care; whether you have a preexisting condition in your family or just [lack] the ability to afford access to health care.”

Big government likes big providers. That’s why ObamaCare is gradually making the local doctor-owned medical practice a relic. In the not too distant future, most physicians will be hourly wage earners, likely employed by a hospital chain.

Why? Because when doctors practice in small offices, it is hard for Washington to regulate what they do. There are too many of them, and the government is too remote. It is far easier for federal agencies to regulate physicians if they work for big hospitals. So ObamaCare shifts money to favor the delivery of outpatient care through hospital-owned networks.

The irony is that in the name of lowering costs, ObamaCare will almost certainly make the practice of medicine more expensive. It turns out that when doctors become salaried hospital employees, their overall productivity falls.

Over one-third of the 9.1 million full-time jobs among America’s diverse business franchises could be cut back or eliminated by Obamacare as small businesses struggle to maintain profitability while coughing up money to pay for Washington-mandated health care coverage, according to the International Franchise Association.

The threat of hitting 3.2 million full-time workers as the Affordable Care Act takes effect next year is prompting the owners of fast food restaurants, service companies and other franchises to urge Congress to make significant changes in Obamacare…

“The ACA has made health care an inextricable cost of running a small business in America and continues to evolve with regard to its cost and complexity for franchisees and franchisors as the law becomes fully implemented ahead of 2014,” said IFA Senior Vice President of Government Relations & Public Policy Judith Thorman. “Preparing your franchise business to deal with the ACA should be a top priority for franchisees and franchisors.”

Federal officials are developing contingency plans in case the health insurance exchanges are not fully ready to begin enrolling people on Oct. 1, the head of the agency that’s building the massive 50-state marketplace structure said last week…

Making contingency plans for October is necessary, Cohen said. “I think it’s only prudent to not assume everything is going to work perfectly on day one and to make sure that we’ve got plans in place to address things that may happen,” added Cohen, whose division is part of the Centers for Medicare and Medicaid Services (CMS)…

Chao was frank about the stress and tension of the compressed time frame involved in setting up the exchanges. “We are under 200 days from open enrollment, and I’m pretty nervous,’’ he said. “I don’t know about you,” he added, to murmurs from the insurance industry audience.

They seem to have forgotten about the third path: the right can replace Obamacare if it fails. And thus far, it gives every indication of failing. It has contributed to growing premium costs. Its budget impacts have been revised only in a negative direction (indeed, the only positives have been from fewer states implementing the Medicaid expansion). It has already been stripped of one mathematically and actuarially unsound entitlement. Most Republican governors have no interest in helping implement a program they believe to be ill-thought from its inception, and even Democrats don’t want their fingerprints at the state level on exchanges and Medicaid expansions their systems can’t handle…

So implementation is going to get messy, and in ways that will impact people’s lives far more directly than the instability of the early days of Medicare Part D. We’re not just talking about getting you a drug, keep in mind – we’re talking about births, limbs, surgery, transplants, life and death. That’s one reason Democrats have already shown themselves willing to be far more critical post-2012. They think this is fine because the law appears secure. But it’s also still very unpopular, with Democratic support dropping substantially since the election. Removed from the conflict of electoral politics, Obamacare requires less ideological fealty, and pointing out its flaws becomes less an act of betrayal than an admission of the obvious.

The central problem here is that Obama promised too much, and Obamacare will deliver too little. The Repeal Coalition will continue to work to undermine it at every opportunity, and the nature of its passage means that there is no foreseeable avenue for the normal bipartisan fixes and tweaks to make a sweeping law work better. Instead, Republicans are likely to seize on every sad story as justification for dramatic changes – and in 2016, mount campaigns designed to replace the system in whole or in part with plenty of material to use in their cause. It’s very possible, perhaps even likely, that moderate Democrats will run in 2014 promising to “fix Obamacare” in one sense or another.

Not only will voters be alienated by changes they dislike, the thinking goes, they’ll also be confronted by the litany of promises Democratic lawmakers made before and after it became law. Rob Jesmer, who served as executive director of the National Republican Senatorial Committee in 2008 and 2010, suggested Republicans might have an easier time making their case in the next election cycle than in 2010.

“Even then, it was all theory,” said Jesmer, who is now a Republican consultant. “What I like about what’s happening in 2014 is we can use statements that were said in 2010 by vulnerable Democrats. They said, ‘You could keep your doctor, and your insurance premiums won’t rise.’ Well, the rubber is going to meet the road in 18 months. Many of them will prove largely not true.”…

The ground is fertile, then, for the issue to reemerge in 2014, because the midterm battleground map will largely be fought where Obamacare is least popular. Deeply red states like West Virginia, South Dakota, and Montana will feature races next year. And several Democrats up for reelection, like Sens. Mary Landrieu in Louisiana, Mark Begich in Alaska, and Mark Pryor in Arkansas, are facing voters for the first time since voting for the legislation in 2010.

The law remains generally unpopular. Conservatives don’t like it because it is expensive and intrusive. But they weren’t going to like it anyway. Obama might have his legacy legislation on firmer footing today if he had done what Johnson did and found a program that could garner at least some bipartisan support. But Obama, always in a hurry, rushed into the legislation, saw it stall, and then rushed into final passage through the use of procedural shenanigans in the Senate…

But what makes Obama’s entitlement vulnerable is that fact that Democrats don’t much like it either…

When 35 members of the Senate Democratic caucus voted to repeal the tax on medical devices like pacemakers and artificial limbs they did so over Obama’s protests and with full knowledge that doing so would make the law more fiscally unsustainable.

The president said that the hardship on medical device makers and their customers would be more than made up for once the law was in full swing and tens of millions more were added to customer rolls with free or partly free insurance. The Senate vote on Thursday night was a very vocal expression of doubt in the president’s promise.

According to the Kaiser Health Tracking Poll for March, only 18 percent of Republicans, 31 percent of independents, and 58 percent of members of Obama’s own party, have a favorable opinion of Obamacare. Overall, Kaiser’s polling indicates that only 37 percent of Americans like Obamacare — down 9 points from Kaiser’s tally in the month immediately following Obamacare’s passage.

By about 2-to-1 margins, Kaiser’s respondents now say that, under Obamacare, they expect the cost of American health care to rise (55 percent), rather than fall (21 percent), and the quality of American health care to fall (45 percent) rather than rise (24 percent). By more than 3-to-1 margins (57 to 16 percent on costs, 55 to 18 percent on quality), independents share these same low expectations for life under Obamacare…

With Obamacare set to roll out in earnest early next year, one hopes that Republicans will learn their lesson. If they forcefully oppose Obamarcare — rather than helping, like some GOP governors, to advance it — and if they articulate a clear and compelling replacement, they will win this war for the future of America. If they don’t, then they (though not the country) will deserve their fate.

Smart conservative health policy analysts have proposed a way to cut the Gordian knot — Remove the tax deduction for health insurance purchases from employers and give it to individuals. This was actually candidate John McCain’s proposal in 2008, though, as Yuval Levin (editor of National Affairs and one of those smart analysts) noted ruefully, “Nobody told John McCain.” As Levin explains, if individuals were given a $5,000 tax credit (fully refundable for those below the poverty line) for the purchase of health insurance, insurance companies would compete to provide excellent coverage for $5,000.

If, in addition, individuals were permitted to shop across state lines for insurance, those states with fewer mandates would be able to offer cheaper plans and would accordingly get more business. Replacing traditional Medicare with premium support would encourage competition in that market, as well…